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Perforated Colon Cancer Mimicking Contaminated Pancreatic Pseudocyst: the Treatment Dilemma Under Urgent Laparotomy

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Perforated Colon Cancer Mimicking Contaminated Pancreatic Pseudocyst: the Treatment Dilemma Under Urgent Laparotomy 206 ANNALS OF GASTROENTEROLOGYC.I. 2004, FOTIADIS, 17(2):206-209 et al Case report Perforated colon cancer mimicking contaminated pancreatic pseudocyst: The treatment dilemma under urgent laparotomy C.I. Fotiadis1, I.A. Kouerinis2, P. Xekouki1, I. Papandreou1, G. Chamalakis1, G.C. Zografos2 SUMMARY Conversely, several degrees of colonic lesions following pancreatic abscess formation have been Non-traumatic colon perforation may be the result of an described: a) localized paralytic ileus of the transverse advanced carcinoma, diverticulitis or inflammatory bowel colon b) Intramural involvement of the colon in a disease. Such perforations are rarely observed in the splenic localized area c) colonic stricture simulating colonic flexure and in special cases mimic pancreatic pseudocysts carcinoma d) colonic bleeding e) colonic fistula1,2. The or abscesses. On the other hand colonic perforation is an incidence of colonic involvement in patients suffering uncommon but potentially lethal complication of a from a pancreatic abscess3,4 is as high as 1% (Table1, 2). pancreatic abscess. Several diagnostic and treatment dilemmas the surgeon has to face as soon as the diagnosis The special radiographic findings which indicate of a splenic flexure abscess has been made are: Is the colonic participation into a peripancreatic abscess are: pancreas or the colon the origin of this lesion? Should a) localized gaseous distention of the transverse colon, 5-7 endoscopic drainage or operation be performed? And if b) colon cut-off sign . Nowadays CT has limited their operation, what kind in such a critically ill patient? Here diagnostic significance as it usually can easily reveal a we report a new case of a perforated colon cancer located in peripancreatic abscess, but it is unable to diagnose the the splenic flexure and mimicking a peripancreatic abscess colonic fistula. Fistulography, whenever possible, e.g. which was initially misinterpreted as a contaminated performed gastric surgery or open drainage of a pan- pancreatic pseudocyst. creatic abscess, remains the most sensitive method in demonstrating the fistulous communication between the peripancreatic abscess and the splenic flexure of the INTRODUCTION colon, and it is always advisable when high index of 8 It is well known to all surgeons that colon perforation suspicion of such a lesion exists . Colonoscopy in cases may result from trauma, cancer, diverticulitis or with suspected pancreatico-colic fistula may be helpful inflammatory bowel disease and, based on different but hazardous (Table 3). parameters, may lead to spread peritonitis or abscess The treatment of colonic fistula formation associated formation. Splenic flexure is an uncommon site of with a peripancreatic abscess is a matter of debate9. perforation, leading potentially to a perineoplasmatic Undoubtedly much experience is needed to determine phlegmon mimicking an abscess of the tail of the which patients are appropriate candidates for endoscopic pancreas. versus surgical management, or what surgical procedure should be performed (Table 4, 5). In our experience a fundamental question must be answered: What is the 1 Third Department of Propaudeutic Surgery, University of Athens, leading cause of the peripancreatic abscess? (Algorithm). Sotiria Hospital, Athens, Greece, 2First Department of Propaudeutic Surgery, University of Athens, Hippokration Hospital, Athens, Greece All reports in the world literature describe this abscess formation as a result of acute pancreatitis or as a Author for correspondence: contamination of a well-known pancreatic pseudocyst. Ilias Kouerinis, Kipselis 17, 11257 Athens, Greece, The surgeon who faces this problem in an urgent e-mail: [email protected] laparotomy must not underestimate the possibility of a Perforated colon cancer mimicking contaminated pancreatic pseudocyst 207 Table 1. Pathogenesis of colon necrosis CASE REPORT Direct congestion of the colon by pancreatic enzymes A critically ill, 78-year-old woman was admitted to Mechanical pressure the Third Department of Propaudeutic Surgery of Sotiria Ischaemia of the colon Hospital with severe abdominal pain, mainly located in - venous infraction the left upper quadrant, and moderate fever (38,2° C). - compression of the marginal vessels On physical examination epigastric and left upper - Thrombosis quadrant tenderness with guarding was noticed, while no masses were palpated. Past medical history revealed prolonged mild pain at the same location without any Table 2. Symptoms of colonic fistula other specific symptoms. Laboratory findings included a 3 Hematohezia hematocrit of 27 per cent, leykocyte count 18.000/cm Unusual rectal drainage of pus or liquid material with left shift, but serum amylase was within normal limits. Chest roentgenogram showed a left pleural Sudden disappear of a previous palpated mass effusion and ultrasonography of the upper abdomen was Sepsis suggestive of a peripancreatic abscess. Exploratory laparotomy was decided which revealed an abscess formation at the tail of pancreas in close relation to the Table 3. Diagnosis splenic colonic flexure. Due to the severe inflammation Barium enema in the area, the operation was limited to external drainage CT (low sensivity) of the abscess. The postoperative course of the patient Fistulography (recommended) was meliorated temporarily under broad-spectrum Colonoscopy (helpful but potentially hazardous) antibiotic therapy. On the fifth postoperative day the Mesenteric angiography (bleeding> 1ml/min) patient became septic and fistulography via the drain was then performed. A fistulous communication between the remaining cavity of the abscess and the splenic flexure Table 4. Criteria for ct-guided needle/endoscopic drainage was demonstrated. Urgent laparotomy was indicated and (stomach or duodenum) extended left hemicolectomy, splenectomy and distal Patient in good condition pancreatectomy were performed, while the remaining Experienced radiologist/endoscopist (familiar to endoscopic cavity was lavaged of debris and purulent material. Both drainage uncomplicated of pseudocysts) frozen and permanent sections were suggestive of Well defined abscess perforated colonic cancer. Postoperatively, antimicrobial Accessible lesion agents based on the culture results were given and the patient progressed uneventfully with gradual remission Absence of internal divides-diaphragms of the fever. At 1 year following surgery the patient is Low viscosity of the purulent material still alive and in good condition. Table 5. Types of operation (Drainage +) DISCUSSION Closure of fistula Pancreatic and peripancreatic abscesses complicate Loop Colostomy acute pancreatitis in 1 to 5 per cent of patients according Partial resection to several reported series4. The mortality rate of these Colostomy + Resection lesions without surgical, endoscopic, or CT guided needle Colostomy+Partial colectomy/+Splenectomy drainage, despite broad-spectrum antibiotics administra- 10 Loop ileostomy tion, approaches 100 per cent . Distal pancreatectomy +Splenectomy+Closure of fistula Colonic involvement in pancreatitis includes localized ileus, mechanical obstruction from an impinging pancreatic phlegmon or abscess, colon necrosis or fistulization11,12. 114 such cases have been described in perforated colon cancer, especially when little is known the world literature and 40 of them involve colonic fistula about the medical history of the patient. formation with an abscess cavity8,13,14. 208 C.I. FOTIADIS, et al Non-traumatic colon perforation is a well-known In conclusion, any case of a peripancreatic abscess phenomenon mostly seen in cancer and diverticulitis, with fistula formation in the colon must not mislead the although it may occasionally occur spontaneously too15. surgeon to the diagnosis of a contaminated pseudocyst, Nevertheless, splenic colon flexure is not a common site but on contrary, it may alert him to perform a radical of perforation and even less of abscess formation16. The operation. close anatomic relationship of the splenic colon flexure with the tail of pancreas can easily mislead the surgeon REFERENCES to consider this abscess formation to be a result of a pancreatic phlegmon or of an infected pancreatic pseu- 1. Grodsinsky C, Ponka JL. The spectrum of colonic involve- docyst, especially when little is known about the past ment in pancreatitis. Dis Colon Rectum 1978; 21:66-70. medical history of the patient17. Moreover, when a colon 2. Lukash WM. Complications of acute pancreatitis. Arch Surg 1967; 94:848-852. fistula formation with such a cavity is diagnosed, despite 3. Abcarian H, Eftaiha M, Kraft AR, Nyhus LM. Colonic the absence of literature reports, there must be a high complications of acute pancreatitis. Arch Surg 1979; index of suspicious on the part of the surgeon the surgeon 114:995-1001. to include in his differential diagnosis perforated colon 4. Thomson WM, Kelvin FM, Rice RP. Inflammation and cancer. If there is any doubt about the origin of the necrosis of the transverse colon secondary to pancreatit- abscess, any attempt at endoscopic or CT-guided needle is. Am J Roentgenol 1997; 128:943-948. drainage must be avoided, despite some good results 5. Price CW. The colon cut-off sign in acute pancreatitis. reported in selected patients18,19. Furthermore, the Med J Aust 1956; 1:313-314. 6. Stuart C. Acute pancreatitis: preliminary investigation of surgeon must be prepared to perform a more radical a new radiodiagnostic sign. J Fac Radiol (London) 1956; operation,
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